SURGEON AT WORK
Transposition of the Basilic Vein for Arteriovenous
Fistula: An Endoscopic Approach
Bernardo D Martinez, MD, FACS, Christopher J LeSar, MD, Thomas J Fogarty, MD, FACS,
Christopher K Zarins, MD, FACS, George Hermann, BS
courses over the medial epicondyle of the humerus, to lie
within the medial bicipital furrow. This vein perforates
the deep fascia at approximately one-third the distal extent of the humerus. Using local anesthesia with occasional intravenous sedation, a 2.5- to 3.0-cm slightly
curved transverse incision is made just medial and 1 cm
superior to the anticubital fossa. Dissection continues to
expose the brachial artery and the basilic vein, using
standard surgical instruments and technique. After assessing the quality of these structures within this wound,
the basilic vein is liberated along its length by ligating
and dividing the visualized venous tributaries. Through
this working incision, using conventional techniques,
the beginning of a subcutaneous tunnel is created over
the basilic vein. This tunnel is extended using the Ethicon endovein harvesting small spoon dissector (Ethicon
Endo-Surgery, Inc, Cincinnati, OH) with a 5-mm, 30degree endoscope (Fig. 2). This device creates an operative working space, allowing mobilization to proceed
along the length of the basilic vein. Dissection is technically achieved with endoscopic instrumentation using
an endoscopic curved scissors, endoscopic forceps, and a
pigtail or ring linear dissector. An endoscopic endoclipping device is used to obtain vascular exclusion and allow division of the subcutaneous venous tributaries.
Dissection proceeds along the length of the basilic
vein under endoscopic vision to carefully avoid injury to
the medial cutaneous nerve, which is found surrounding
the vein superiorly and inferiorly along its length. Next,
the basilic vein is followed as it dives and penetrates the
aponeurotic fascial plane. It is critical to meticulously
perform this maneuver to avoid injury to the median
and ulnar nerves adjacent to the vein in this region.
When the appropriate length of the vein has been
liberated above and below the anticubital fossa, a 1-cm
transverse counter incision is placed directly over the
basilic vein 2 cm inferior to where the pectoralis major
muscle inserts into the humerus. The vein is retrieved
through the uppermost incision and, under gentle dilation with dilute heparin saline, all tributaries that have
The creation of a functional hemodialysis fistula in patients who develop end-stage renal disease (ESRD) has
critical importance. The majority of surgeons would
agree that a primary radiocephalic arteriovenous fistula
is the procedure of choice in new dialysis patients. But in
patients who lack adequate forearm vasculature secondary procedures are indicated. Currently, in the United
States, more than 50% of hemodialysis that is performed
occurs through polytetrafluoroethylene (PTFE) grafts.1
Numerous reports have described the various complications of PTFE grafts, including high primary failure
rates and multiple thrombotic events during the life of
the graft. Because of the frequency of graft thrombosis in
these patients yearly surgical intervention may be required.2,3 Recent reports on longterm upper arm dialysis
access procedures, specifically, the transposed brachiobasilic arteriovenous fistula, have shown significant
longterm primary patency rates reaching 70% at 8
years.4 To date there have been no descriptions of a minimally invasive approach to address the long morbid
upper arm dissection needed to create this fistula (Fig.
1). We describe an effective, technically simple, minimally invasive surgical approach to create an upper arm
transposed brachiobasilic fistula.
TECHNIQUE
The upper extremity has multiple variations in venous
anatomic patterns, necessitating preoperative mapping
of both upper arms with duplex ultrasonography to determine position and caliber of the veins. The portion of
the basilic vein used to create the vascular access arises
approximately 10 cm below the anticubital fossa, and
No competing interests declared.
Received February 24, 2000; Revised June 30, 2000; Accepted September 13,
2000.
From St. Vincent Mercy Medical Center and Medical College of Ohio, Toledo, OH, Division of Vascular Surgery (Martinez, LeSar); Stanford University School of Medicine, Division of Vascular Surgery, Palo Alto, CA (Fogarty,
Zarins); Fogarty Research, Portola Valley, CA (Hermann).
Correspondence address: Christopher LeSar, MD, 3122 Hopewell Pl, Toledo, OH 43606.
© 2001 by the American College of Surgeons
Published by Elsevier Science Inc.
233
ISSN 1072-7515/01/$21.00
PII S1072-7515(00)00796-1
234
Martinez et al
J Am Coll Surg
Transposition of the Basilic Vein
Figure 1. Standard incision used to perform a traditional brachiobasilic fistula.
been clipped are suture-ligated with nonabsorbable vascular sutures (Fig. 3).
The basilic vein, brought superficially, is transposed
and drawn through a lateral subcutaneous tunnel in a
gentle curving fashion to the region of the brachial artery
in the anticubital fossa. The length of the basilic vein
harvested will dictate the outer curving trajectory of the
tunnel and affect the landing and angle of the anastomosis (Fig. 4). Ensuring an adequate length of vein is
prudent, and can be obtained by dividing the basilic vein
2 to 3 cm below the anticubital fossa incision. A 5-mm
arteriovenous anastomosis is created in an end-to-side
fashion with the spatulated end of the vein to the side of
the brachial artery. At the completion of the procedure
the functional dynamics of the newly created fistula are
evaluated. This is done by assessing the arterial outflow
to the hand using Doppler ultrasonography. The two
wounds are closed in standard fashion.
RESULTS
During a 10-month period from January 1999 to October 1999, nine consecutive patients were identified who
required placement of a brachiobasilic arteriovenous fistula. These patients were not candidates for primary
radiocephalic or brachiocephalic fistulas because of poor
venous anatomy demonstrated on ultrasound. The majority of these patients had end-stage renal disease from
diabetes and required dialysis, and others had nephropathy from hypertension, hepatitis C, and HIV. One patient had a diagnosis of polycythemia vera and required
frequent phlebotomy.
The procedure as described was technically completed in all patients, and the fistulas were assessed at 19
months. Eight fistulas were in current use and one patient thrombosed the brachiobasilic fistula 24 hours
postoperatively. This fistula was not revascularized because of findings of prior thrombophlebitis in the basilic
vein at the original operation. The thrombophlebitis was
not seen on preoperative ultrasound or retrospectively.
In the remaining eight patients the average time to fistula maturation was 2.6 months, as determined by surgical permission to use fistula or by the first use of the
access. There were no technical factors delaying the first
use of the fistula, and the average time was 4.4 months.
Figure 2. Under direct endoscopic vision a subcutaneous tunnel is created to dissect the basilic vein.
Vol. 192, No. 2, February 2001
Martinez et al
Transposition of the Basilic Vein
235
Figure 3. The basilic vein after mobilization is retrieved through the upper incision and all
venous tributaries would be ligated.
The average total time of fistula use in these eight patients was 12.6 months, for a total of 101 patientmonths of fistula patency. The overall primary patency
rate at the averaged 1 year was 88% (8 of 9). There were
no other thromboses in these patients, but other complications included transient parastesias in the operative
arm (1), iatrogenic hematoma formation at cannulation
site (1), venous stenosis (2), and venous aneurysm (1).
During routine fistula surveillance venous stenoses were
noted and addressed by angioplasty and surgical revision, respectively. The venous aneurysm found on surveillance was corrected surgically. The immediate advantages of this approach were fast healing times, no
infections, minimal scarring, and minimal postoperative
edema.
DISCUSSION
Surgeons today are facing increasing demands to provide
dialysis access in the growing population of patients with
ESRD maintained on chronic hemodialysis. The traditional approach to vascular access has been creation of a
radiocephalic arteriovenous fistula. Current trends in
the United States show that prosthetic fistulas are used in
more than 80% of primary dialysis access procedures.5
Cumulative 1-year and 2-year primary patency rates for
PTFE fistulas range from 44% to 70% and 35% to
49%, respectively.2,6,7 Fistulas created with a transposed
basilic vein sutured end to side to the brachial artery have
been shown to be the most reliable and dependable secondary vascular access procedure reported for chronic
hemodialysis. Primary patency rates for the first and second year range from 80% to 90% and 74% to 86%,
respectively, with a longterm patency of 70% at 8 years
reported in a large series.4,6,8 Despite the advantages of
this vascular access procedure—which include excellent
primary patency, a single anastomosis, lack of a graftvenous anastomosis (the most common site of graft failure), low incidence of infection, relocation of the scar from
the cannulation zone, and high flow rates generated with
a basilic-axilliary run-off—the procedure has not increased in favor presumably because of the extensive upper arm dissection required to create this dialysis access.
Minimally invasive vascular surgical techniques were
incorporated into this procedure to address this issue of
Figure 4. A new superficial lateral tunnel is created, allowing the basilic vein to be transposed
and anastomosed to the brachial artery.
236
Martinez et al
J Am Coll Surg
Transposition of the Basilic Vein
the extensive upper arm incision, allowing us to capitalize on the advantages offered by autologous fistulas. Creation of adequate space achieved with the Ethicon subcutaneous dissector allows the operation to proceed
smoothly. Under videoscopic guidance, dissection of the
structures of the upper arm can be accomplished under
direct vision, adding to the technical simplicity and ease
of performing the procedure. The advantages of autologous fistulas are numerous and the morbidity experienced by patients, the yearly health care cost, and the
demand on surgeons to maintain vascular access may be
reduced with the wider use of these procedures. This
minimally invasive vascular surgical approach eliminates
the extensive dissection required with conventional surgery, and achieves all the advantages offered by autologous vascular access.
Acknowledgment: We would like to thank Stephen Kramer
of Kramer Graphics for the art work, and Christine Newman
for her editing skills in preparing this manuscript.
REFERENCES
1. United States Renal Data System. The USRDS dialysis morbidity
and mortality study: Wave 2. Am J Kidney Dis 1997;30:S67–
S85.
2. Culp K, Flanigan M, Taylor L, Rothstein M. Vascular access
thrombosis in new hemodialysis patients. Am J Kidney Dis
1995;26:341–346.
3. Schuman ES, Gross GF, Hayes JF, Standage BA. Long-term patency of polytetrafluorethylene graft fistulas. Am J Surg 1988;
155:644–646.
4. Dagher FJ. The upper arm AV hemoaccess: long term follow-up.
J Cardiovasc Surg 1986;27:447–449.
5. Windus DW. Permanent vascular access: a nephrologist’s view.
Am J Kidney Dis 1993;21:457–471.
6. Coburn MC, Carney WI. Comparison of basilic vein and polytetrafluoroethylene for brachial arteriovenous fistula. J Vasc Surg
1994;20:6:896–904.
7. Matsuura JH, Rosenthal D, Clark M, et al. Transposed basilic
vein versus polytetrafluoroethylene for brachial-axillary arteriovenous fistula. Am J Surg 1998;176:219–221.
8. Hakaim AG, Nalbandian M, Scott T. Superior maturation and
patency of primary brachiocephalic and transposed basilic vein
arteriovenous fistulae in patients with diabetes. 1998;27:1:154–
157.